­The Diversity, Equity, and Inclusion (DEI) bill will make mandatory continuing education requirements relating to DEI for providers, including physicians, physician assistants, psychologists, psychiatric nurse practitioners, behavior analysts, assistant behavior analysts, marriage and family therapists, clinical professional counselors, social workers, and alcohol and drug abuse counselors. Currently, these providers are required to obtain a specific number of continuing education credits for license renewal, of which ethics and suicide training are mandatory. Despite academic training programs requiring coursework in cultural diversity both in academic work and field experience, there seems to be a disconnect between training programs and licensure requirements as there are currently no mandatory requirements for continuing education in DEI for licensed providers in Nevada.

Nevada is a remarkably diverse State with nearly half of the population identifying as racially and/or ethnically diverse according to the 2019 U.S. Census. In fact, 29% of the population identifies as Latinx, 10% are African American, 8% are Asian, 4% identify as multiracial, nearly 2% are Native American, and 0.8% identify as Hawaiian or Pacific Islander. Notably, DEI extends beyond race and ethnicity, including the intersections of ability, socioeconomic status (SES), gender, and sexual orientation. In fact, close to 9% of Nevadans under the age of 65 identifies as experiencing a disability and over 12% live in poverty (U.S. Census, 2019).

About 4.5% of the U.S. population identify as LGBTQ (Gallup, 2018) with nearly 40% experiencing a mental illness. The U.S. foreign-born population and their U.S. born children is about 90 million, with unique mental health challenges faced by this population (Pew Research Center, 2020). According to the U.S. Department of Health and Human Services Office of Minority Health, non-Hispanic Blacks are about twice as likely to experience psychological distress, yet half as likely to have access to health care for treatment. It fairs worse for our American Indian/Alaska Native populations who are 2.5 times more likely to experience serious psychological distress (National Center for Health Statistics, 2018).

Licensed mental health providers are often not equipped to provide culturally competent treatment to diverse populations such as these mentioned above as the providers are often not informed of culturally relevant factors and therefore cannot be culturally responsive without training and education. This presents many implications for the diagnosis, treatment, and outcomes of these populations given health disparities, barriers to treatment, and cultural factors that further stigmatize mental health. For instance, individuals growing up with low SES are more likely to experience trauma, higher rates of stress, and are more likely to experience adverse childhood experiences all of which negatively impact mental health (American Psychological Association, 2017). Notably, these rates are even higher for black, indigenous, people of color (BIPOC) and often result in the criminalization and/or misdiagnosis of these populations. Researchers found that Latinx and African American adults are more likely to experience PTSD and have more severe and chronic symptoms compared to White adults despite high rates of mental health service utilization (Sibrava, Bjornsson, Perez Benitez, Moitra, Weisberg, & Keller, 2019). These high rates of PTSD were attributed to lack of culturally competent trauma treatments paired with a lack of understanding of how discrimination and racism impacts both Latinx & African Americans to develop and incorporate culturally responsive intervention strategies (Sibrava et al., 2019)

Children of color are more likely to be diagnosed with a behavioral condition such as oppositional defiance disorder, conduct disorder, and/or ADHD compared to their White counterparts. With regard to ability and neurodiversity, children of color are less likely to be diagnosed with autism at an early age (i.e., before the age of three years) despite research indicating that the earlier the diagnosis, the better the prognosis. In fact, low SES children and children of color are less likely to be diagnosed early on as they are “missed” or they are misdiagnosed. Mandell, Listerud, Levy, and Pinto-Martin (2002) found that Medicaid-eligible Latinx and African American children were diagnosed over a year later and required a significant higher number of visits to obtain the diagnosis compared to their White counterparts.

Similarly, African American men are more likely to be misdiagnosed with schizophrenia which has been attributed to implicit biases by clinicians which result in the over pathologizing of African Americans (Neighbors, Trierweiler, Ford, & Muroff, 2003). However, it is also likely that the lack of cultural responsiveness may result in a lack of sensitivity to cultural differences in symptom presentation, consequently, leaving clinicians vulnerable to their own implicit biases, stereotypes, and negative attitudes to certain populations due to their lack of training in culturally responsive assessment and diagnosis (Neighbors et al., 2003).

Continuing education requirements are intended to ensure licensed mental health professionals stay current, stay informed, and provide the best care possible for the individuals to whom we are providing treatment. We must understand not only the unique challenges faced by diverse communities, but also comprehend cultural background, value systems, and appropriate evidence-based treatment approaches that address mental health challenges from a culturally competent intersectional perspective. Diversity education is not a “problem” or nuisance to ignore, but rather a necessity and an opportunity for us to learn more fully about groups who have historically been marginalized based on racial, sex/gender, and/or sexual orientation, among other social identities.

A lack of cultural understanding by mental health providers due to lack of education and training in DEI is not only a competency issue, but an ethical one as well. Culturally competent treatment is espoused as a basic tenet of all mental health accrediting bodies in the U.S. however there are no current requirements in DEI for continuing education in Nevada as there are for suicide prevention and ethics. Currently, New Mexico, the District of Columbia, Georgia, Maryland, and Texas are the only States requiring DEI continuing education hours.

Mental health disparities and the misdiagnoses of BIPOC continues to raise significant concerns in clinical settings.  Men, women, and children of color are more likely to be misdiagnosed with a psychotic disorder, learning disorder and behavioral disorders (Friedman & Paradis, 2019). Thus, understanding implicit biases, microaggressions, cultural differences, barriers to adequate healthcare, stigma in mental health pertaining to underserved and marginalized communities as well as understanding historical context associated with mistrust of providers could reduce mental health disparities and misdiagnoses of BIPOC. DEI training can also be effective with identifying and raising awareness regarding social justice issues and how BIPOC may be affected clinically by those issues. Licensed mental health professionals provide services to vulnerable, marginalized, stigmatized and underserved communities. Therefore, it is of the utmost importance that providers are promoting and advocating for equality, equity, and inclusion through culturally responsive service delivery which can only be obtained through continuing education requirements in diversity, equity, and inclusion.